What is an overview of diaphragmatic pacemakers (artificial pacing devices)?

From the Guidelines

Diaphragmatic pacers are a viable option for providing ventilatory support in carefully selected patients with central hypoventilation syndrome, offering increased mobility and improved quality of life. These devices work by electrically stimulating the phrenic nerve to cause diaphragm contraction, generating breathing using the patient's own diaphragm as the respiratory pump 1. The ideal candidates for diaphragmatic pacing include patients with no or mild intrinsic lung disease, intact phrenic nerve-diaphragm axis integrity, and presence of a tracheostomy, at least initially 1.

Key Considerations

• Bilateral implantation of phrenic nerve electrodes and diaphragm pacer receivers is recommended to achieve optimal ventilation in children 1.
• Diaphragm pacing is typically used for 12 to 15 hours per day, allowing patients to participate in supervised age-appropriate activities while receiving assisted ventilation 1.
• The primary benefit of diaphragm pacing is freedom from the mechanical ventilator during daytime use, with the aim of minimizing the need for mechanical ventilation and potentially removing the tracheostomy in older patients who use the diaphragm pacers during sleep time only 1.
• Patients who rely on diaphragm pacing require continuous monitoring with pulse oximetry and P ETCO2, as well as continuous care by a highly trained registered nurse 1.

Potential Complications and Precautions

• Obstructive apnea can be a complication of diaphragm pacing during sleep, which may be overcome by adjusting settings on the pacers to lengthen inspiratory time and/or decrease the force of inspiration 1.
• Patients using diaphragm pacing should have spare antennae at home, as these are the components that most frequently break, and a back-up diaphragm pacer transmitter already set based on physiologic study in a center with extensive expertise in diaphragm pacing 1.

From the Research

Overview of Diaphragmatic Pacers

• Diaphragmatic pacers are used to stimulate the diaphragm in patients with ventilator-dependent spinal cord injuries and central hypoventilation syndromes 2, 3, 4, 5, 6
• The goal of diaphragmatic pacing is to wean patients from mechanical ventilation and restore efficient breathing 2, 3, 4, 5, 6
• There are two main techniques used in diaphragmatic pacing: intrathoracic diaphragm pacing (IT-DP) and intraperitoneal diaphragm pacing (IP-DP) 2

Indications and Effectiveness

• Diaphragmatic pacing is effective in weaning selected patients from ventilator dependence and improving their quality of life 2, 3, 4, 5, 6
• The procedure has been shown to be effective in patients with high-level spinal cord injuries and central hypoventilation syndromes 2, 3, 4, 5, 6
• Studies have reported ventilator-weaning rates of 72% to 96% in patients with IT-DP and IP-DP 2
• Diaphragmatic pacing has also been shown to reduce the rate of respiratory tract infections and improve mobility, speech, and olfaction in patients 4

Patient Selection and Implantation

• Patient selection is critical to the success of diaphragmatic pacing, and patients must have intact phrenic nerves and a functional diaphragm 2, 3, 4, 5, 6
• The pacing electrode is typically implanted directly on the phrenic nerve or on the diaphragm at the phrenic nerve motor point 5
• Complications associated with diaphragmatic pacing are infrequent and include wire breakage, radiofrequency failure, and infection 4

Future Directions

• Diaphragmatic pacing may have potential applications in patients with other types of respiratory failure, such as amyotrophic lateral sclerosis or temporary scenarios in intensive care unit patients 5
• Further studies are needed to evaluate the effectiveness of diaphragmatic pacing in these patient populations and to determine the long-term outcomes of the procedure 2, 3, 4, 5, 6